Provider Demographics
NPI:1225453517
Name:ROTH, RYAN L (APRN)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:L
Last Name:ROTH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 ALBANY AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06120-2508
Mailing Address - Country:US
Mailing Address - Phone:860-249-9625
Mailing Address - Fax:860-808-1580
Practice Address - Street 1:415 KILLINGWORTH RD
Practice Address - Street 2:
Practice Address - City:HIGGANUM
Practice Address - State:CT
Practice Address - Zip Code:06441-4370
Practice Address - Country:US
Practice Address - Phone:860-345-8535
Practice Address - Fax:860-345-8678
Is Sole Proprietor?:No
Enumeration Date:2014-02-24
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT994473133V00000X
MARN2284731163W00000X
CT5832363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily